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Understanding the ‘social’ in social anxiety

By medicalising social anxiety as wholly a problem of the individual we risk overlooking the potential social drivers

By Matthew Barca, University of Melbourne

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Lia* believes her social anxiety will never go away because she is ‘built’ and ‘born’ that way. She feels it is in her genes. As a result, she turns to medication to help manage it.

“I am on (medication) and I don’t have any issue with it because it has done so much for me. I was a mess without it. I can’t say I can’t function without it, but I am a lot better when I am on it.”

People living with social anxiety can see their problem as a biological or genetic flaw, but what role does society play? Picture: Shutterstock

Lia is one of eight people living with social anxiety who I’ve interviewed as part of my explorative research (an honour thesis) into how people understand, live with and manage their social anxiety. I say exploratory because the sample size of the research is small and there’s also been minimal research done on people’s experiences and understandings of a disorder that is now one of Australia’s most self-reported mental health conditions.

A key finding of the research is that people living with social anxiety viewed their condition in large part as a problem caused by some biological or genetic flaw, which they themselves have to manage, whether through medication or cognitive behavioural interventions.

While many mention significant social factors — such as an abusive relationship, bullying or other undesirable life experiences that have contributed to their social anxiety - they ultimately view these as experiences that were ‘triggered’ by an inherent disposition. That is, they saw factors within themselves as more foundational to the causes of their social anxiety than the negative experiences in their social environment.

This finding is important because social anxiety is still a ‘contested illness’, in that there is no single, definable cause or origin, and it is a condition that inherently relates to the social world.

Despite this, the people I’ve interviewed feel it is more a problem at an individual level than at a social level. This poses an important question: why are these people living with social anxiety so certain their condition is “them” rather than — in some sense at least — “us”? Why is it spoken of primarily as an individual disorder that bears on biological traits and not as a social phenomenon?

This is a massive increase from a 1995 self-reported survey that, based on extrapolation, only an estimated 390,000 Australians met the criteria for a disorder in social anxiety.

An estimated 2.4 million people in Australia meet the current diagnostic criteria for a disorder in social anxiety. Picture: Raw Pixel/Unsplash

This increase in social anxiety disorder rates possibly reflects a broadening of its diagnostic criteria. The Diagnostic Statistical Manual (DSM), an official diagnostic resource that clinicians refer to when identifying maladaptive behavioural and cognitive symptoms in individuals, first introduced social anxiety as a diagnosis in 1980.

It was identified as a ‘persistent’ and ‘irrational fear’ of ‘scrutiny by others’ in social spaces. It was understood to be ‘relatively rare’ and would only be diagnosed in people who had a phobia and ‘significant distress’ to a specific social stimulus such as walking or eating in public.

However, since 1994, the DSM now describes the condition as ‘the marked or persistent fear of one or more social or performance situations’. No longer does someone have to have an ‘irrational phobia’ to a specific social situation, instead, it is more broadly understood to be feelings of fear or worry in social settings like going to parties or family events.

The notion that a social anxiety disorder is primarily genetic or biological is far from an established fact in the scientific community, yet it is something that most participants feel to be true. For these people at least, social anxiety is understood as a medical condition that is situated at the individual level. But this is problematic.

When we understand human behaviour only in medical terms and language, it takes on a medical character and becomes something to be treated medically. Certainly, there is great benefit and utility in medicalising human conditions since it can lead to effective medical interventions and treatments.

But there are also some implications.

Medicalisation individualises conditions that may have their origins and causes, at least partly, in the social environment rather than in just the human body. Consequently, we risk overlooking potentially important social factors and it may impact how we understand mental health conditions.

Social anxiety is understood to be feelings of fear or worry in social settings like going to parties. Picture: George Gvasalia/ Unsplash

Another implication of medicalisation is it may impact where people look for support and help. By understanding a condition as an ‘individual’ problem, we may turn to interventions that focus more on treating the individual, such as behavioural therapy or medication, which is also apparent in my research. While these interventions undeniably help individuals in living with their social anxiety, they still, in part, medicalise the condition because it depicts the individual as the subject in need of treatment and intervention.

But if we also understand social anxiety as a ‘social problem’, we can begin to try and identify the social drivers of the condition.

For example, is contemporary society putting more pressure on people to be social by increasingly valuing extraversion and confidence? Do we sanction people who violate unwritten social expectations, like not being in your first relationship by a certain age or deciding not to drink alcohol and go out partying when turning eighteen? Do we collectively scrutinise people who find it difficult to socialise and interact in particular settings, which then may go on to worsen their social anxiety? And, what is in our day-to-day interactions, and our larger social norms and attitudes, that may contribute to the condition?

By continuing to just focus on medicalising social anxiety, we may risk simply further isolating the condition as just another illness that should be treated and managed on an individual level.

Social anxiety is a real and distressing condition for those who experience it. As Martin*, a man in his 20s living with the disorder, told me: “there are certain social situations that I would want to engage in, but due to my social anxiety, I would avoid them altogether - stuff like relationships, starting a relationship. I generally avoid social outings or avoid meeting new people, you know. I will just retreat in my home.”

While the existing medicalised model has many benefits, it may be that we should also consider social anxiety from a social perspective; by doing this, it may lead somebody like Lia not to just blame herself or her genes when she experiences social anxiety, but start putting some of the spotlight on society.

The author is continuing exploratory research on social anxiety as part of a PhD.

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